July 13, 2026

Individualizing Buprenorphine: Low-dose Induction to Long-acting Injectables

26 minutes

In this episode of ASAM Practice Pearls, Dr. Stephen Taylor hosts Dr. Stephen Holt in a discussion about practical strategies for initiating and managing patients receiving low-dose buprenorphine and long-acting injectable (LAI) formulations. The conversation explores how to match induction approaches to individual patient needs, guidance on dosing, and ways to support ongoing use, cravings, or withdrawal symptoms. This episode offers listeners practical insights for implementing buprenorphine treatment strategies and expanding access to evidence-based care.

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Host

Stephen M. Taylor, MD, MPH, DFAPA, DFASAM

Dr. Stephen M. Taylor is ASAM's President and is board certified in general psychiatry, child and adolescent psychiatry, addiction psychiatry, and addiction medicine. With over 30 years of practice experience, Dr. Taylor is dedicated to helping adolescents and adults overcome addiction and co-occurring psychiatric disorders. He has served as the Medical Director of the NBA and NBPA Player Assistance and Anti-Drug Program for 16 years and is the Chief Medical Officer of Pathway Healthcare, which operates multiple outpatient addiction and mental health treatment offices across six states.

Expert

Stephen Holt, MD, MS, FACP, FASAM

Dr. Stephen Holt has been an attending physician at Yale-New Haven Hospital since 2008 and is an Associate Professor of Medicine at Yale School of Medicine. He is the Director of the Yale Addiction Recovery Clinic and the Associate Program Director for Yale's Primary Care Internal Medicine Residency Program. He is board-certified in Addiction Medicine and Internal Medicine. He has published and lectures frequently on a variety of addiction medicine topics, and has won numerous teaching awards at the local, regional, and national levels.

📖 Show Segments

00:05 - Introduction

00:45 - Patient Case: Erratic use of Buprenorphine

02:23 - Deciding Between Traditional and Low-Dose Induction

05:27 - Direct-to-Inject Approach and Access Logistics

09:23 - Low-dose Induction Approach

10:38 - Considerations for Tailoring Buprenorphine Doses

12:37 - Candidates for LAI Formulations

14:16 - Initiating LAI Treatment

17:56 - Managing Ongoing Use and Breakthrough Symptoms on LAI

21:02 - Addressing Co-occurring Substance Use Disorders

23:05 - Practice Pearls

25:31 - Conclusion and Additional Learning Opportunity 

📋 Key Takeaways

Match your induction strategy to the patient: Patients using short-acting or predictable opioids can follow a traditional induction. For those taking predictable long-acting opioids or methadone, consider a low-dose induction. For patients with erratic use of buprenorphine or fentanyl, consider a direct-to-inject or high-dose induction approach.

Low-dose induction reduces the risk of precipitated withdrawal: Start a patient with very small amounts of buprenorphine (e.g., 0.5 mg) while the patient continues using their opioid, then gradually increase their buprenorphine dose over approximately 6 days in the outpatient setting.

Consider direct-to-inject LAI buprenorphine for patients with unstable use: LAI buprenorphine (especially 7-day formulations) allows a gradual receptor transition, reducing withdrawal risk and simplifying care for patients with unstable opioid use patterns.

Proactively address logistical barriers to offering LAIs: Establish feasible workflows (e.g., specialty pharmacy or buy-and-bill) to reduce access barriers. Another option is to plan follow-up visits a few days later to administer the injection and use sublingual buprenorphine as a bridge, rather than trying to secure LAI same-day access upfront.

Individualize LAI dosing based on patient use patterns and context: There's no perfect conversion from fentanyl to buprenorphine. Dosing decisions depend on opioid type, level of cravings, and environment. Patients using more than 2-3 bags of fentanyl per day may require the maximum dose of LAI buprenorphine, whereas lighter users may not.

Offer LAI buprenorphine as a routine option to all patients: No patient is "too stable" or "too unstable" for LAI buprenorphine. While it is especially helpful for patients with erratic adherence, housing instability, or a preference for injections, any patient can benefit. LAI buprenorphine should be offered as a standard option for everyone.

Breakthrough symptoms on LAIs can be managed with flexible strategies: Options include increasing LAI dose, switching formulations, adding short-term sublingual buprenorphine, and addressing underlying causes of symptoms, such as psychosocial factors.

Pair medication treatment with additional supports: Even with LAIs, providing behavioral support, psychosocial interventions, and treating co-occurring substance use disorders remain essential for long-term recovery. Schedule frequent visits and encourage behavioral support, group therapy, and psychosocial interventions.

Start with just one patient: Clinicians hesitant about LAI buprenorphine should start with a single patient. Find a specialty pharmacy in your area and make the connection. The learning curve is manageable, and the impact is often transformative.

🔗 Resources

ASAM 57th Annual Conference Sessions:

Enhancing Access with Direct-to-Inject Buprenorphine: Evidence and Implementation

Long-Acting Injectable Buprenorphine for Birthing and Parenting People with OUD

LAI Buprenorphine in Criminal Justice Settings: Strategies and Tools for Implementation

ASAM Clinical Tips Advanced Buprenorphine Video Series: Explore HERE

Extended-Release (XR) Buprenorphine Formulations Resource Guide - This resource guide compares two formulations of extended-release (XR) buprenorphine, a long-acting treatment for opioid use disorder (OUD). It highlights differences in dosing, administration, and logistics to support informed clinical decision-making.

ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids - Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. J Addict Med. 2023;17(6):632-639. doi:10.1097/ADM.0000000000001202

Extended-Release 7-Day Injectable Buprenorphine for Patients With Minimal to Mild Opioid Withdrawal - D'Onofrio G, Herring AA, Perrone J, et al. JAMA Netw Open. 2024;7(7):e2420702. Published 2024 Jul 1. doi:10.1001/jamanetworkopen.2024.20702

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In support of improving patient care, the American Society of Addiction Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

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